Article

The Role of Law in Public Health Preparedness: Opportunities and Challenges

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

We report the results of a study designed to assess and evaluate how the law shapes the public health system's preparedness activities. Based on 144 qualitative interviews conducted in nine states, we used a model that compared the objective legal environment with how practitioners perceived the laws. Most local public health and emergency management professionals relied on what they perceived the legal environment to be rather than on an adequate understanding of the objective legal requirements. Major reasons for the gap include the lack of legal training for local practitioners and the difficulty of obtaining clarification and consistent legal advice regarding public health preparedness. Narrowing the gap would most likely improve preparedness outcomes. We conclude that there are serious deficiencies in legal preparedness that can undermine effective responses to public health emergencies. Correcting the lack of legal knowledge, coupled with eliminating delays in resolving legal issues and questions during public health emergencies, could have measurable consequences on reducing morbidity and mortality.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... The first call to address the issue of health system legislation was published by the Institute of Medicine in 1988 (44). This call was heeded after different emergency events that occurred during the first decade of the twenty-first century (the World Trade Center attack in 2001, the mailing of envelopes containing anthrax, the SARS epidemic in 2003, and Hurricane Katrina in 2005) (45). These natural disasters and man-made events significantly impacted US society and government (35). ...
... As such, there are various methodologies that prove efficient in studying these mechanisms. The integration of legislation into emergency management still seems to be a relatively neglected area (45). According to Jacobson et al. (45), this is due to the lack of recognition that information about public health laws promotes best practices during emergencies. ...
... The integration of legislation into emergency management still seems to be a relatively neglected area (45). According to Jacobson et al. (45), this is due to the lack of recognition that information about public health laws promotes best practices during emergencies. Fox (55) noted two methodological concerns regarding research on health policy governance and diseases. ...
Article
Background: Public health legal preparedness (PHLP) for emergencies is a core component of the health system response. However, the implementation of health legal preparedness differs between low- and middle-income countries (LMIC) and developed countries. Objective: This paper examines recent trends regarding public health legal preparedness for emergencies and discusses its role in the recent Ebola outbreak. Design: A rigorous literature review was conducted using eight electronic databases as well as Google Scholar. The results encompassed peer-reviewed English articles, reports, theses, and position papers dating from 2011 to 2014. Earlier articles concerning regulatory actions were also examined. Results: The importance of PHLP has grown during the past decade and focuses mainly on infection–disease scenarios. Amid LMICs, it mostly refers to application of international regulations, whereas in developed states, it focuses on independent legislation and creation of conditions optimal to promoting an effective emergency management. Among developed countries, the United States’ utilisation of health legal preparedness is the most advanced, including the creation of a model comprising four elements: law, competencies, information, and coordination. Only limited research has been conducted in this field to date. Nevertheless, in both developed and developing states, studies that focused on regulations and laws activated in health systems during emergencies, identified inconsistency and incoherence. The Ebola outbreak plaguing West Africa since 2014 has global implications, challenges and paralleling results, that were identified in this review. Conclusions: The review has shown the need to broaden international regulations, to deepen reciprocity between countries, and to consider LMICs health capacities, in order to strengthen the national health security. Adopting elements of the health legal preparedness model is recommended.
... The first call to address the issue of health system legislation was published by the Institute of Medicine in 1988 (44). This call was heeded after different emergency events that occurred during the first decade of the twenty-first century (the World Trade Center attack in 2001, the mailing of envelopes containing anthrax, the SARS epidemic in 2003, and Hurricane Katrina in 2005) (45). These natural disasters and man-made events significantly impacted US society and government (35). ...
... As such, there are various methodologies that prove efficient in studying these mechanisms. The integration of legislation into emergency management still seems to be a relatively neglected area (45). According to Jacobson et al. (45), this is due to the lack of recognition that information about public health laws promotes best practices during emergencies. ...
... The integration of legislation into emergency management still seems to be a relatively neglected area (45). According to Jacobson et al. (45), this is due to the lack of recognition that information about public health laws promotes best practices during emergencies. Fox (55) noted two methodological concerns regarding research on health policy governance and diseases. ...
Article
Full-text available
Background: Public health legal preparedness (PHLP) for emergencies is a core component of the health system response. However, the implementation of health legal preparedness differs between low- and middleincome countries (LMIC) and developed countries. Objective: This paper examines recent trends regarding public health legal preparedness for emergencies and discusses its role in the recent Ebola outbreak. Design: A rigorous literature review was conducted using eight electronic databases as well as Google Scholar. The results encompassed peer-reviewed English articles, reports, theses, and position papers dating from 2011 to 2014. Earlier articles concerning regulatory actions were also examined. Results: The importance of PHLP has grown during the past decade and focuses mainly on infection�disease scenarios. Amid LMICs, it mostly refers to application of international regulations,whereas in developed states, it focuses on independent legislation and creation of conditions optimal to promoting an effective emergency management. Among developed countries, the United States’ utilisation of health legal preparedness is the most advanced, including the creation of a model comprising four elements: law, competencies, information, and coordination. Only limited research has been conducted in this field to date.Nevertheless, in both developed and developing states, studies that focused on regulations and laws activated in health systems during emergencies, identified inconsistency and incoherence. The Ebola outbreak plaguing West Africa since 2014 has global implications, challenges and paralleling results, that were identified in this review. Conclusions: The review has shown the need to broaden international regulations, to deepen reciprocity between countries, and to consider LMICs health capacities, in order to strengthen the national health security. Adopting elements of the health legal preparedness model is recommended
... As the authors themselves observed, the challenge for future research is to integrate legal variables with the wider range of structural capacity and other factors depicted infigure 1 in a design that will support causal inference. Most recently, Jacobson and colleagues investigated how federal and state laws influence the preparedness of public health systems as reflected in the knowledge and attitudes of 144 agency staff, their legal counselors , and their legislative staffers in nine states (Jacobson et al. 2011). Explicit criteria were used to select sites that varied by key characteristics (per capita health expenditure, geographic region, organization of the public health system, and level of emergency preparedness), and semistructured interviews were used to elicit what laws the respondents thought were influencing preparedness and how. ...
... Explicit criteria were used to select sites that varied by key characteristics (per capita health expenditure, geographic region, organization of the public health system, and level of emergency preparedness), and semistructured interviews were used to elicit what laws the respondents thought were influencing preparedness and how. Although the study did not explicitly use sociolegal theories of individual or organizational legal consciousness, the researchers took it as given that there were " gaps between the objective and perceived legal environments " and that much of the explanation of how law influences preparedness would be found in them (Jacobson et al. 2011). The study found that local public health agency practitioners were ill informed and poorly advised about legal requirements influencing preparedness. ...
... The study of how legal authority or other legal factors influence the day-to-day practices of health agencies is in its infancy. There are, as far as we know, no studies other than that by Jacobson and colleagues (Jacobson et al. 2011 ) that observe and assess the actual dayto-day exercise of general legal authority within health agencies, let alone any that draw on (and test) the elements that figure 1 posits as important. The impact of interventional health laws is the most fully developed topic area of PHLR. ...
Article
Context: For three decades, experts have been stressing the importance of law to the effective operation of public health systems. Most recently, in a 2011 report, the Institute of Medicine recommended a review of state and local public health laws to ensure appropriate authority for public health agencies; adequate access to legal counsel for public health agencies; evaluations of the health effects and costs associated with legislation, regulations, and policies; and enhancement of research methods to assess the strength of evidence regarding the health effects of public policies. These recommendations, and the continued interest in law as a determinant of health system performance, speak to the need for integrating the emerging fields of Public Health Law Research (PHLR) and Public Health Systems and Services Research (PHSSR). Methods: Expert commentary. Findings: This article sets out a unified framework for the two fields and a shared research agenda built around three broad inquiries: (1) the structural role of law in shaping the organization, powers, prerogatives, duties, and limitations of public health agencies and thereby their functioning and ultimately their impact on public health ("infrastructure"); (2) the mechanisms through which public health system characteristics influence the implementation of interventional public health laws ("implementation"); and (3) the individual and system characteristics that influence the ability of public health systems and their community partners to develop and secure enactment of legal initiatives to advance public health ("innovation"). Research to date has laid a foundation of evidence, but progress requires better and more accessible data, a new generation of researchers comfortable in both law and health research, and more rigorous methods. Conclusions: The routine integration of law as a salient factor in broader PHSSR studies of public health system functioning and health outcomes will enhance the usefulness of research in supporting practice and the long-term improvement of system performance.
... The law is an important tool to strengthen emergency management and public health disaster preparedness and response [1], support equity, and policies and practices that promote individual and community resilience. The US Constitution established the American government structure with its separation of powers and principle of federalism. ...
... It is clear that civil rights protections can never be waived during emergencies, disasters or pandemics, although apparently there is confusion about that issue among some professionals in the field [52]. Jacobson and colleagues' [1] research indicates that both local public health practitioners and emergency managers don't accurately understand the law and base decisions on perceptions rather than actual legal requirements. Sherry and Harkins [24] concur that emergency managers are confused about legal requirements; they argue that non-compliance may be caused by concerns about unrealistic legal requirements. ...
Chapter
Full-text available
This chapter focuses on civil rights issues related to emergencies, disasters and pandemics. The chapter begins with a discussion of the Americans with Disabilities Act of 1990 (ADA) and Section 504 of the Rehabilitation Act of 1973 (Section 504) which prohibit disability discrimination broadly, including in relation to emergencies. The chapter summarizes the legal requirements that disabled people have “physical access,” “program access” and “effective communication” (including “auxiliary aids and services”), in the “most integrated setting,” with “reasonable modifications” (accommodations) as needed. Despite strong anti-discrimination laws, there have been persistent, well-documented challenges to achieving legal compliance. Since there is no one list of all possible reasonable modifications, the chapter shares examples of potential compliance solutions derived from court decisions, legal settlements, and a US Department of Justice compliance programs. The chapter then touches on the issue of equity when modifying usual healthcare standards, a topic of discussion during the COVID-19 pandemic and other times where there is concern about potentially scarce medical resources. People with disabilities may identify as members of more than one historically marginalized group, so the chapter summarizes civil rights laws applicable to populations other than people with disabilities, such as racial and ethnic minorities. Some erroneously assume that any law can be waived (temporarily suspended) in an emergency, but this is not necessarily the case. This chapter concludes with a discussion about emergency waivers using the HIPAA (Health Insurance Portability and Accountability Act) privacy and health information security law and civil rights laws as examples.
... Evidence reveals that concern or confusion about various legal protections during public health emergencies may interfere with providers' responsiveness and willingness to volunteer. 2,7,11,26,[29][30][31][32][33][34][35] Ethically, providing necessary medical care should not be hampered by legal considerations. ...
... 7 In addition, equal protection claims may arise from individuals who believe they received inferior services because of their race, ethnicity, or socioeconomic class. 29,48 Failure to Prepare Health care entities have an obligation to prepare for emergencies, and lawsuits against hospitals and other health care entities alleging liability for patient harms are brought and settled routinely in the United States. 30,56,57 When patient harms can be linked to an entity's failure to prepare sufficiently for emergencies, defending the claims can be difficult because emergency preparedness is mandated by law, endorsed by practice, and ultimately beneficial to patients. ...
Article
Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been in the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. Concepts explored in this technical report will help to inform pediatric health care providers, advocates, and policy makers about the complexities of how providers are currently protected, with a focus on areas of unappreciated liability. The timeliness of this technical report is emphasized by the fact that during the time of its development (ie, late summer and early fall of 2017), the United States went through an extraordinary period of multiple, successive, and overlapping disasters within a concentrated period of time of both natural and man-made causes. In a companion policy statement (www.pediatrics.org/cgi/doi/10.1542/peds.2018-3892), recommendations are offered on how individuals, institutions, and governments can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.
... Before business owners can be properly educated on public health law, there must be a comprehensive understanding of the law from those who teach these business owners. However, there is a gap in that understanding for public health law from a legal standpoint as well as the public health standpoint (Jacobson, Wasserman, Botoseneanu, Silverstein, & Wu, 2012;Kaufman, Allan, & Ibrahim, 2012;Smith, 2009). Health experts choose to err on the side of caution in the promotion of health, while legal counsel and lawmakers uphold it to the fullest, and tend to focus on the legitimacy of the law, as opposed to the public health benefit. ...
... Health experts choose to err on the side of caution in the promotion of health, while legal counsel and lawmakers uphold it to the fullest, and tend to focus on the legitimacy of the law, as opposed to the public health benefit. Jacobson et al. (2012) says it best, "An effective implementation process is therefore integral to the effective use of the law…because legislative objectives are likely to be interpreted differently at various levels of government" (p. 312). ...
Article
Full-text available
One of the many reasons for smoking litigation against public health agencies such as a health department is due in part to the gap between public health education and knowledge of the laws by those who are regulated by these policies. This research study examined the effectiveness of public health instruction and curriculum from the New York City Department of Health and Mental Hygiene (NYCDOHMH), and its effect on knowledge of the law as it relates to business owners. N = 74 business owners were surveyed using a pre/post study design to determine their knowledge of public health law. Results of the study found the education to be 'somewhat' effective, while other factors suggested a gap in the knowledge of public health law still existing among business owners. Given this lack of advanced knowledge, suggestions for curricular and instruction improvements are offered for the promotion of more effective public health pedagogy.
... CSMs present an opportunity for local emergency management, public health organizations, and healthcare coalitions to engage community partners in preparedness efforts, assess and enhance public health and emergency plans, and access potential new resources. Public health and emergency management organizations have different priorities and organizational cultures, often impeding partnership [63], however a CSM offers the opportunity to bridge that gap. The meeting provides the circumstance for local public health, emergency management and other local government entities, for profit and non-profit organizations, and community groups and their members to collaborate. ...
Chapter
Full-text available
This chapter focuses on a local (city, town, county) “whole community” inclusive approach to emergency planning and response. This approach encompasses addressing community members’ “access and functional needs,” broad categories of need rather than specific labels or diagnoses. Planning and response that address these needs will also likely address many of the barriers people with disabilities and others face during disasters or pandemics. Using the “CMIST” (communication, maintain health, independence, support/safety/self-determination, and transportation) framework to operationalize these needs makes planning and response more efficient, effective, and provides a focus to meet regulatory obligations. For example, people who are Deaf, Blind, have an intellectual disability or dementia may have communication needs (the C in CMIST), although they may require different accommodations such as American Sign Language (ASL) interpretation, Braille text, and simplified or picture based communication. The focus of the chapter then shifts to community based organizations and emergency manager and public health personnel beliefs about the whole community approach. The chapter also provides an example of the approach in action. At a Community Stakeholder Meeting community members, organizations, local government representatives, and others review the local emergency plan and response practices to identify strengths and gaps relating to disability inclusion. After identifying gaps, the group collaboratively sets priorities and creates a strengths based action plan for remediation. The chapter closes with a discussion of civic engagement (community member participation in public decision making) and lessons learned from civic engagement that might strengthen the whole community approach.
... Monetary and technology resources can merge the roles and responsibilities of public health preparedness and emergency management [14]. Severe deficiencies in legal preparedness can undermine effective responses to public health emergencies [15,16]. These were the essential factors in dealing with public health emergencies. ...
Article
Full-text available
Background: At the end of 2019, the outbreak of coronavirus disease 2019 (COVID-19) severely damaged and endangered people's lives. The public health emergency management system in China has played an essential role in handling the response to the outbreak, which has been appreciated by the World Health Organization and some countries. Hence, it is necessary to conduct an overall analysis of the development of the health emergency management system in China. This can provide a reference for scholars to aid in understanding the current situation and to reveal new research topics. Methods: We collected 2247 international articles from the Web of Science database and 959 Chinese articles from the China National Knowledge Infrastructure database. Bibliometric and mapping knowledge domain analysis methods were used in this study for temporal distribution analysis, cooperation network analysis, and co-word network analysis. Results: The first international article in this field was published in 1991, while the first Chinese article was published in 2005. The research institutions producing these studies mainly existed in universities and health organizations. Developed countries and European countries published the most articles overall, while eastern China published the most articles within China. There were 52 burst words for international articles published from 1999-2018 and 18 burst words for Chinese articles published from 2003-2018. International top-ranked articles according to the number of citations appeared in 2005, 2007, 2009, 2014, 2015, and 2016, while the corresponding Chinese articles appeared in 2003, 2004, 2009, and 2011. Conclusions: There are differences in the regional and economic distribution of international and Chinese cooperation networks. International research is often related to timely issues mainly by focusing on emergency preparedness and monitoring of public health events, while China has focused on public health emergencies and their disposition. International research began on terrorism and bioterrorism, followed by disaster planning and emergency preparedness, epidemics, and infectious diseases. China considered severe acute respiratory syndrome as the starting research background and the legal system construction as the research starting point, which was followed by the mechanism, structure, system, and training abroad for public health emergency management.
... Jacobson et al. previously observed that public health is often characterized by a risk-averse culture prone to underestimating risks of delay while overestimating risks of acting too soon. 8 But evolving issues inherently involve gaps in understanding and thus both action and inaction must be based on conscious, proactive decisions. Likewise, public health agencies must preserve their role as trusted risk communicators by consistently and timely providing credible, unbiased information to the public, addressing community concerns, and fairly considering conflicting data. ...
Article
Full-text available
The Flint water crisis demonstrates the importance of adequate legal preparedness in dealing with complicated legal arrangements and multiple statutory responsibilities. It also demonstrates the need for alternative accountability measures when public officials fail to protect the public's health and explores mechanisms for restoring community trust in governmental public health.
... taking refuge within a hospital) or evacuating § § § § (i.e., the mass physical movement of patients and staff) hospitals. Public health legal preparedness plays an essential role in enabling the government to fulfill its duty by providing the necessary legal framework to respond to catastrophic disasters (Jacobson, Wasserman, Botoseneanu, Silverstein & Wu, 2012;Moulton, Gottfried, Goodman, Murphy & Rawson, 2003). ...
... Yet there are some significant gaps that compromise the effectiveness of public health law. First, a recent study found substantial weaknesses in the overall clarity, direction, and cohesion of the laws governing public health emergencies, and that legal knowledge is inadequately developed and disseminated (Jacobson et al. 2012). This means that practitioners are not benefiting from timely legal advice to resolve significant public health challenges. ...
... 11 Within this broader context of public health legal authority, public health legal preparedness plays an essential role in enabling the government to fulfill its duty by providing the necessary legal framework to respond to catastrophic disasters. 12,13 ''Public health legal preparedness'' is defined as the attainment by a public health system (eg, a community, state, region, or nation) of legal benchmarks essential to the readiness of that system to respond to health threats. Scholars identify 4 core elements requisite to achieving public health legal preparedness: (1) laws or legal authorities; (2) competencies (ie, abilities, skills) of those responsible for applying the law; (3) information to aid these individuals in applying the law; and (4) coordination across sectors and jurisdictions. ...
Article
Full-text available
Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses-such as ordering evacuation of or sheltering-in-place in hospitals-when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.
... A 2012 study of the law and public health preparedness and response discovered a large disconnect between actual legal conditions and perception of the law, and found that the primary motivation for action in public health events was the perception of legal authority (Jacobson et al. 2012). Similarly, our research found that officials tended to respond to the pandemic according to their perception of legal authority and their understanding of the most effective method to produce the desired public health goal. ...
Article
Applying qualitative historical methods, we examined the consideration and implementation of school closures as a nonpharmaceutical intervention (NPI) in thirty US cities during the spring 2009 wave of the pA(H1N1) influenza pandemic. We gathered and performed close textual readings of official federal, state, and municipal government documents; media coverage; and academic publications. Lastly, we conducted oral history interviews with public health and education officials in our selected cities. We found that several local health departments pursued school closure plans independent of CDC guidance, that uncertainty of action and the rapidly evolving understanding of pA(H1N1) contributed to tension and pushback from the public, that the media and public perception played a significant role in the response to school closure decisions, and that there were some notable instances of interdepartmental communication breakdown. We conclude that health departments should continue to develop and fine-tune their action plans while also working to develop better communication methods with the public, and work more closely with education officials to better understand the complexities involved in closing schools. Lastly, state and local governments should work to resolve lingering issues of legal authority for school closures in times of public health crises.
... The vast majority of respondents indicated that the current governmental public health culture does not support PHE. Governmental public health tends to be risk averse and rule bound and cannot move fast enough to take advantage of entrepreneurial opportunities. 15 According to respondents, entrepreneurship would be a disruptive change to the existing culture because public health professionals are averse to business concepts. Therefore, LHDs would "need to inculcate a new philosophy of business." ...
Article
Objectives: We assessed the feasibility and desirability of public health entrepreneurship (PHE) in governmental public health. Methods: Using a qualitative case study approach with semistructured interview protocols, we conducted interviews between April 2010 and January 2011 at 32 local health departments (LHDs) in 18 states. Respondents included chief health officers and senior LHD staff, representatives from national public health organizations, health authorities, and public health institutes. Results: Respondents identified PHE through 3 overlapping practices: strategic planning, operational efficiency, and revenue generation. Clinical services offer the strongest revenue-generating potential, and traditional public health services offer only limited entrepreneurial opportunities. Barriers include civil service rules, a risk-averse culture, and concerns that PHE would compromise core public health values. Conclusions: Ongoing PHE activity has the potential to reduce LHDs' reliance on unstable general public revenues. Yet under the best of circumstances, it is difficult to generate revenue from public health services. Although governmental public health contains pockets of entrepreneurial activity, its culture does not sustain significant entrepreneurial activity. The question remains as to whether LHDs' current public revenue sources are sustainable and, if not, whether PHE is a feasible or desirable alternative.
... 8 The research to date on willingness to respond strongly suggests the need for greater understanding by health department leaders and line staff of the ethical and attendant legal dimensions of infectious disease response in advance of an outbreak. 9,10 The decision of local health department employees to respond to an infectious disease crisis can become a balance of personal (eg, family wellbeing) and professional (eg, welfare of the community served by the health department during the event) responsibilities. A tension thus emerges between their rights as individuals and their commitment to the public good. ...
Article
According to the Institute of Medicine, the local health department workforce is at the hub of the public health emergency preparedness system. A growing body of research has pointed to troubling attitudinal gaps among local health department workers, a vital response cohort, regarding willingness to respond to emergent infectious disease threats, ranging from naturally occurring pandemics to bioterrorism events. A summary of relevant literature on the empirical evidence, ethical norms, and legal standards applicable to the willingness of public health professionals to respond to an infectious disease emergency is presented. Recommendations are proposed for future work to be done to bring the relevant empirical, ethical, and legal considerations together to develop practical guidance for the local response to infectious disease emergencies.
Preprint
Full-text available
Background: At the end of 2019, the outbreak of the coronavirus disease 2019 (COVID-19) had severely damaging people’s life. China’s public health emergency management system had played an essential role in the handling and response of it, which had been appreciated by the World Health Organization and some countries. Hence it is necessary to make an overall analysis of the development of China’s health emergency management system. It can provide a reference for scholars to understand the current situation and look for new research points. Methods: We collected 2247 international from the Web of Science database, 959 Chinese articles from China National Knowledge Infrastructure database. Bibliometric and mapping knowledge domains analysis methods were used in this study for temporal distribution analysis, cooperation network, co-word network analysis. Results: The first international article in this field was published in 1991, while Chinese in 2005. Research institutions mainly come from universities and health institutions. Developed countries and European countries published more articles, while east of China published more. There are 52 burst words for international articles from 1999–2018, while 18 burst words for Chinese articles from 2003–2018. International top-ranked articles by citation appeared in 2005, 2007, 2009, 2014, 2015, 2016, while Chinese appeared in 2003, 2004, 2009, 2011. Conclusions: There are differences in the regional or economic distribution of international and Chinese cooperation networks. International research often relates to hot issues, mainly focus on the emergency preparedness and monitoring for public health events, while China’s focus on the public health emergency and their disposal. International begins the research with terrorism and bioterrorism, followed by disaster planning and emergency preparedness, epidemics and infectious diseases. China takes severe acute respiratory syndrome as the research background and legal system construction as the research starting point, followed by mechanism, structure, system, and learning from abroad of public health emergency management.
Article
Policy Points • A major factor explaining government actors’ failure to mitigate or avert the Flint, Michigan, water crisis is the sheer complexity of the laws regulating how governmental agencies maintain and monitor safe drinking water. Coordination across agencies is essential in dealing with multiple legal arrangements. • Public health legal authority and intervention mechanisms are not self‐executing. Legal preparedness is essential to efficiently navigating complex legal frameworks to address public health threats. • The Flint water crisis demonstrates the importance of democracy for protecting the public's health. Laws responding to municipal fiscal distress must be consistent with expected norms of democracy and require consideration of public health in decision making. Context The Flint, Michigan, water crisis resulted from a state‐appointed emergency financial manager's cost‐driven decision to switch Flint's water source to the Flint River. Ostensibly designed to address Flint's long‐standing financial crisis, the switch instead created a public health emergency. A major factor explaining why the crisis unfolded as it did is the complex array of laws regulating how governmental agencies maintain and monitor safe drinking water. Methods We analyzed these legal arrangements to identify what legal authority state, local, and federal public health and environmental agencies could have used to avert or mitigate the crisis and recommend changes to relevant laws and their implementation. First, we mapped the legal authority and roles of federal, state, and local agencies responsible for safe drinking water and the public's health—that is, the existing legal environment. Then we examined how Michigan's emergency manager law altered the existing legal arrangements, leading to decisions that ignored the community's long‐term health. Juxtaposed on those factors, we considered how federalism and the relationship between state and local governments influenced public officials during the crisis. Findings The complex legal arrangements governing public health and safe drinking water, combined with a lack of legal preparedness (the capacity to use law effectively) among governmental officials, impeded timely and effective actions to mitigate or avert the crisis. The emergency manager's virtually unfettered legal authority in Flint exacerbated the existing complexity and deprived residents of a democratically accountable local government. Conclusions Our analysis reveals flaws in both the legal structure and how the laws were implemented that simultaneously failed to stop and substantially exacerbated the crisis. Policymakers need to examine the legal framework in their jurisdictions and take appropriate steps to avoid similar disasters. Addressing the implementation failures, including legal preparedness, should likewise be a priority for preventing future similar crises.
Article
The Health in All Policies (HiAP) approach aims to integrate health into decisions across sectors to address the social determinants of health and enhance health equity. Jurisdictions interested in implementing this approach may seek clarification about how to operationalize it. Public health legal preparedness provides useful lessons for HiAP. While there are important differences between these two areas, there are also critical similarities. These similarities are particularly important because HiAP and public health preparedness are complementary. Law has been essential in advancing public health preparedness by helping to: (1) prioritize planning; (2) allocate responsibility; (3) enhance collaboration and coordination; (4) establish responsive funding; and (5) emphasize the needs of vulnerable populations. Law can be used similarly to advance HiAP.
Article
In the last five years, the American public health emergency preparedness and response system has been tested by two significant threats, H1N1 and Ebola. While neither proved as dangerous as initially feared, these viruses highlighted on-going issues with collaborations in the field of public health and health care. Strengths were identified within the network, but also challenges that must be resolved before the U.S. faces a major pandemic. Employing interview data from public health emergency response practitioners and documentary evidence from the H1N1 and Ebola responses, this qualitative analysis uses the grounded theory approach to identify key areas for collaborative improvement. The grounded theory developed calls for a stronger policy framework at the federal level to facilitate more collaboration between U.S. agencies and facilitate more collaboration at the state and local level. © 2016, Southern Public Administration Education Foundation, Inc. All rights reserved.
Article
Full-text available
Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses—such as ordering evacuation of or sheltering-in-place in hospitals—when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.
Article
Laws, ordinances, regulations, and executive orders create the powers and duties of public health agencies and modify the complex community conditions that affect health. Appropriately trained legal counsel serving as legal advisors on the health officer's team facilitate clear understanding of the legal basis for public health interventions and access to legal tools for carrying them out. Legal counsel serve public health agencies via different organizational arrangements — e.g., internal staff counsel, external counsel from the state attorney general's (AG) office, state health department, county or city, or private counsel under contract, or in combination. As of 2011, most state health departments (63%) employ their own counsel, and 56% use AG counsel, while 17% contract with independent attorneys; most local health departments (66%) work with attorneys and legal staff assigned by local government, by the state health agency (23%), or contract with outside attorneys and legal staff (15%).
Article
Introduction For effective responses to emergencies, individuals must have the ability to respond and also be willing to participate in the response. A growing body of research points to gaps in response willingness among several occupational cohorts with response duties, including the Emergency Medical Services (EMS) workforce. Willingness to respond is particularly important during an influenza or other pandemic, due to increased demands on EMS workers and the potential for workforces to be depleted if responders contract influenza or stay home to care for sick dependents. State emergency preparedness laws are one possible avenue to improve willingness to respond.Hypothesis Presence of certain state-level emergency preparedness laws (ie, ability to declare a public health emergency; requirement to create a public health emergency plan; priority access to health resources for responders) is associated with willingness to respond among EMS workers.Methods Four hundred twenty-one EMS workers from the National Registry of Emergency Medical Technicians’ (NREMT's) mid-year Longitudinal EMT Attributes and Demographics Study (LEADS) were studied. The survey, which included questions about willingness to respond during an influenza pandemic, was fielded from May through June 2009. Survey data were merged with data about the presence or absence of the three emergency preparedness laws of interest in each of the 50 US states. Unadjusted logistic regression analyses were performed with the presence/absence of each law and were adjusted for respondents’ demographic/locale characteristics.Results Compared to EMS workers in states that did not allow the government to declare a public health emergency, those in states that permitted such declarations were more likely to report that they were willing to respond during an influenza pandemic. In adjusted and unadjusted analyses, this difference was not statistically significant. Similar results were found for the other state-level emergency preparedness laws of interest.Conclusion While state-level emergency preparedness laws are not associated with willingness to respond, recent research suggests that inconsistencies between the perceived and objective legal environments for EMS workers could be an alternative explanation for this study's findings. Educational efforts within the EMS workforce and more prominent state-level implementation of emergency preparedness laws should be considered as a means to raise awareness of these laws. These types of actions are important steps toward determining whether state-level emergency preparedness laws have the potential to promote response willingness among EMS workers. L Rutkow, JS Vernick, CB Thompson, RG Pirrallo, DJ Barnett. Emergency preparedness law and willingness to respond in the EMS workforce. Prehosp Disaster Med. 2014;29(4):1-6 .
Article
Law plays a critical role in all stages of a public health emergency, providing an infrastructure for planning, response, and recovery efforts. A growing body of research has underscored the potential for certain types of state laws, such as those granting liability protections to responders, to influence the public health workforce's participation in emergency responses. It is therefore especially important to focus on particular state-level laws that may be associated with individuals' increased or decreased willingness to respond. We conducted a systematic identification and analysis of specific state emergency preparedness laws that may affect individuals' willingness to respond and offer recommendations for policymakers seeking to promote more effective responses to public health emergencies.
Article
Full-text available
Assessing inter-rater reliability, whereby data are independently coded and the codings compared for agreements, is a recognised process in quantitative research. However, its applicability to qualitative research is less clear: should researchers be expected to identify the same codes or themes in a transcript or should they be expected to produce different accounts? Some qualitative researchers argue that assessing inter-rater reliability is an important method for ensuring rigour, others that it is unimportant; and yet it has never been formally examined in an empirical qualitative study. Accordingly, to explore the degree of inter-rater reliability that might be expected, six researchers were asked to identify themes in the same focus group transcript. The results showed close agreement on the basic themes but each analyst `packaged' the themes differently.
Article
Full-text available
Effective management of modern public health emergencies requires the coordinated efforts of multiple agencies representing various disciplines. Organizational culture differences between public health (PH) and emergency management (EM) entities may hinder inter-agency collaboration. We examine how PH and EM differ in their approach to PH law and how such differences affect their collaboration towards PH preparedness. We conducted 144 semi-structured interviews with local and state PH and EM officials between April 2008 and November 2009. Thematic qualitative analysis in ATLAS.ti was used to extract characteristics of each agency's approach to PH legal preparedness. Two conflicting approaches to the law emerge. The PH approach is characterized by perceived uncertainty regarding legal authority over preparedness planning tasks; expectation for guidance on interpretation of existing laws; and concern about individual and organizational liability. The EM approach reveals perception of broad legal authority; flexible interpretation of existing laws; and ethical concerns over infringement of individual freedoms and privacy. Distinct interpretations of preparedness law impede effective collaboration for PH preparedness. Clarification of legal authority mandates, designation within laws of scope of preparedness activities and guidance on interpretation of current federal and state laws are needed.
Article
Full-text available
We sought to ascertain the types of ethical challenges public health practitioners face in practice and to identify approaches used to resolve such challenges. We conducted 45 semistructured interviews with public health practitioners across a range of occupations (e.g., health officers, medical directors, sanitarians, nurses) at 13 health departments in Michigan. Through qualitative analysis, we identified 5 broad categories of ethical issues common across occupations and locations: (1) determining appropriate use of public health authority, (2) making decisions related to resource allocation, (3) negotiating political interference in public health practice, (4) ensuring standards of quality of care, and (5) questioning the role or scope of public health. Participants cited a variety of values guiding their decision-making that did not coalesce around core values often associated with public health, such as social justice or utilitarianism. Public health practitioners relied on consultations with colleagues to resolve challenges, infrequently using frameworks for decision-making. Public health practitioners showed a nuanced understanding of ethical issues and navigated ethical challenges with minimal formal assistance. Decision-making guides that are empirically informed and tailored for practitioners might have some value.
Article
Full-text available
Sampling is a very complex issue in qualitative research as there are many variations of qualitative sampling described in the literature and much confusion and overlapping of types of sampling, particularly in the case of purposeful and theoretical sampling. The terms purposeful and theoretical are viewed synonomously and used interchangeably in the literature. Many of the most frequent misinterpretations relate to the disparate meanings and usage of the terminology. It is important that the terminology is examined so that underlying assumptions be made more explicit. Lack of shared meanings and terminology in the nursing discourse creates confusion for the neophyte researcher and increases the production of studies with weak methodologies. This paper analyses critically purposeful and theoretical sampling and offers clarification on the use of theoretical sampling for nursing research. The aim is not to make prescriptive statements on sampling; rather, to enhance understanding of the differences between purposeful and theoretical sampling for nursing research.
Article
Full-text available
To determine the influence of a state's legal environment and a hospital's Prenatal Substance Exposure (PSE) protocol on physicians' propensity to respond when prenatal substance exposure is suspected. Using a sample of 1367 physicians from every state and the District of Columbia, we formulate a set of linear models to determine the impact of the legal environment and hospital protocol on physicians' response to PSE, the agreement between physicians' perceptions and actual state legal environments, and physicians' motivation to act when PSE is suspected. Both protocol and legal environment showed to be significantly correlated with physicians' propensity to take action when PSE is suspected (p < 0.05). Our analysis shows that physicians prefer a public health (patient-centered) approach to more punitive measures. Our results suggest a policy strategy focused first on enacting laws that would encourage a patient-centered approach, by developing and using hospital protocols to implement state policy, and then on educating physicians about the actual legal environment.
Article
Full-text available
Conservatives are taking aim at the field of public health, targeting its efforts to understand and control environmental and social causes of disease. Richard Epstein and others contend that these efforts in fact undermine people's health and well-being by eroding people's incentives to create economic value. Public health, they argue, should stick to its traditional task--the struggle against infectious diseases. Because markets are not up to the task of controlling the transmission of infectious disease, Epstein says, coercive government action is required. But market incentives, not state action, he asserts, represent our best hope for controlling the chronic illnesses that are the main causes of death in industrialized nations. In this article, we assess Epstein's case. We consider his claims about the market's capabilities and limits, the roles of personal choice and social influences in spreading disease, andthe relationship between health and economic inequality. We argue that Epstein's critique of public health over-reaches, oversimplifies, and veils his political and moral preferences behind seemingly objective claims about the economics of disease control and the determinants of disease spread. Public health policy requires political and moral choices, but these choices should be transparent.
Article
Chemical regulation is based on science, but that does not mean it is always logical. The way exposure limits have been determined for perchlorate in groundwater - initially associated with spilled rocket fuel but now found to be ubiquitous - shows how public health problems and the resources directed to address them are too often mismatched.
Chapter
Continually changing health threats, technologies, science, and demographics require that public health professionals have an understanding of law sufficient to address complex new problems as they come into being. This book provides a review of the legal basis and authorities for the core elements of public health practice and solid discussions of existing and emerging high-priority areas where law and public health intersect. Each chapter is authored jointly by experts in law and public health. This second edition features three new chapters, with several others revised and updated. New chapters address such topics as the statutory bases for US public health systems and practice, the judiciary role in public health, and chronic disease prevention and control. The book begins with a section on the legal basis for public health practice, including foundations and structure of the law, discussions of the judiciary, ethics and practice of public health, and criminal law and international considerations. The second section focuses on core public health applications and the law, and includes chapters on legal counsel for public health practitioners, legal authorities for interventions in public health emergencies, and considerations for special populations. The third section discusses the law in controlling and preventing diseases, injuries, and disabilities. This section includes chapters on genomics, vaccinations, foodborne illness, STDs, reproductive health, chronic disease control, tobacco use, and occupational and environmental health.
Article
Using the 2005 National Association of County and City Health Officers Profile of Local Health Departments data set, bivariate probit and Heckman selection models were used to test the hypothesis that the level of federal funding received for bioterrorism preparedness is related to the preparedness activities undertaken by local health departments. Overall budget, leadership, and crisis experience are found to be the most important determinants of local preparedness activity, but Centers for Disease Control and Prevention preparedness funding plays a mediating role by building capacity through the hiring of one key leadership position, the emergency preparedness coordinator. Additional research is needed to determine the potential impact of these funds on other aspects of the local public health system, such as the scope of services delivered, to determine secondary effects of the program.
Article
We examine the process by which antitobacco laws and ordinances were implemented and enforced in seven states and nineteen localities. Our findings indicate that state- and local-level clean indoor air laws were rarely enforced by governmental agencies. Instead, these laws were largely self-enforcing in that changed social norms regarding appropriate smoking behavior led to generally high compliance rates. In contrast, teen access laws were not self-enforcing, but were often enforced through periodic vendor compliance checks. We also found that antitobacco forces did not devote a significant amount of attention to implementation and enforcement issues. Their focus was primarily on enacting new legislation and fighting tobacco industry attempts to weaken existing laws. Our results do not augur well for public health measures that require state-level enforcement and that are opposed by powerful and politically well-connected interests. For tobacco control laws to be effective, public health advocates need to consider the locus of enforcement responsibility and the sanctions available to the enforcement agency, such as license removal by local authorities. These results suggest that failure to specify such mechanisms in the legislation will lead to delays in implementing and enforcing the laws as well as to a number of compliance problems. Antitobacco coalitions will also need to become more actively involved in the implementation and enforcement process.
Article
Public health emergencies have occurred throughout history, encompassing such events as plagues and famines arising from natural causes, disease pandemics interrelated with wars (such as the influenza pandemic of 1918-1919), and industrial accidents such as the 1986 Chernobyl disaster, among others. Law and legal tools have played an important role in addressing such emergencies. Three prime U.S. examples are Congressional authorization of quarantine as early as 1796, legally mandated smallpox vaccination upheld in a landmark 1905 U.S. Supreme Court ruling, and the President's 2003 executive order adding SARS to the federal government's list of “quarantinable communicable diseases.” The public health emergencies of the present — both actual and potential — pose equally serious threats but do so in the context of greatly magnified expectations that stem directly from the attacks of September 11, 2001, and the immediately following anthrax attacks.
Article
As public health practitioners are no doubt aware, public health practice and politics are closely linked. Although theoretical discussion of the emerging field of public health ethics has been rich, scholars have paid little attention to the relationship between ethical issues and politics in public health practice. We conducted semistructured interviews with 45 public health practitioners across a range of occupations (eg, health officers, medical directors, sanitarians, nurses, educators, and commissioners) working at 12 local health departments across Michigan and the state health department. Practitioners were asked to describe the ethical issues they faced in their daily practice. Ethical issues that resulted from the political environment emerged as one major category of ethical issues our interviewees described. This article illustrates how political issues engender ethical challenges in 4 main areas: public health agenda-setting, political pressures, political conflicts with best practices, and the scope of public health practice. The findings suggest that politics and public health ethics intrinsically intersect, because political pressures and priorities often impose ethical challenges that practitioners negotiate in their daily work.
Assessing the Impact of Federal Law on Public Health Preparedness
  • Berkman
Tobacco Control Laws: Implementation and Enforcement
  • Jacobson